when caring for a child with probable appendicitis the nurse should be alert to recognize which sign or symptom as a manifestation of perforation
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Nursing Elites

ATI RN

ATI Nursing Care of Children 2019 B

1. When caring for a child with probable appendicitis, the nurse should be alert to recognize which sign or symptom as a manifestation of perforation?

Correct answer: C

Rationale: When caring for a child with probable appendicitis, sudden relief from pain is a critical sign that could indicate perforation of the appendix. Perforation results in the release of pressure and inflammation, leading to a temporary relief of pain. Anorexia (loss of appetite) and decreased abdominal distention are symptoms commonly associated with appendicitis itself, not perforation. Bradycardia (slow heart rate) is not typically a direct manifestation of appendicitis or its complications.

2. Which is the most frequently used test for measuring visual acuity?

Correct answer: A

Rationale: The Snellen letter chart is the most commonly used test for measuring visual acuity, particularly in school-age children and adults.

3. The mother of a 3-month-old breastfed infant asks about giving her baby water because it is summer and very warm. What should the nurse tell her?

Correct answer: A

Rationale: Breast milk provides adequate hydration, even in warm weather, so additional fluids like water are not necessary and can interfere with breastfeeding.

4. A newborn is admitted to the nursery with a complete bilateral cleft lip and palate. The mother refuses to see or hold her infant. What should the nurse do first?

Correct answer: D

Rationale: In this situation, the priority is to acknowledge and validate the mother's feelings, creating a supportive environment for her. Option D is correct as it focuses on recognizing and allowing the mother to express her emotions. This approach can help build trust and facilitate communication. Options A and B are incorrect as they do not address the mother's emotional needs and may come across as dismissive. Option C is less appropriate as it only encourages expression without explicitly recognizing the mother's current emotional state.

5. A 6-year-old child has patient-controlled analgesia (PCA) for pain management after orthopedic surgery. The parents are worried that their child will be in pain. What should your explanation to the parents include?

Correct answer: C

Rationale: PCA pumps are designed to deliver both a continuous baseline dose and patient-activated bolus doses, which can help manage pain effectively while minimizing the risk of overdose.

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